Overcrowding and poor cleanliness have been criticised in a report on a maternity unit where 10 women have died in the past three years.
The maternity unit at Northwick Park was investigated
The Healthcare Commission investigated the services at Northwick Park Hospital in Harrow, north-west London.
In April, the commission called in an outside team of doctors and midwives to help improve the situation after finding "serious system failures".
It also found intimidating managers and some racist behaviour in the unit.
Thursday's report outlines events at the NHS trust before the special measures were announced.
In the past three years 10 women have died at Northwick Park's maternity unit, which sees around 5,000 births a year
In the UK an average of about one mother in 8,700 dies in childbirth.
It said that many of the comments from women who had used the maternity unit related to the care environment.
"Concerns were raised about overcrowding and poor standards of cleanliness, particularly in toilets and bathrooms," the report said.
"Women also commented that there was no designated bin to put babies' soiled nappies into on the postnatal ward.
"There were sometimes insufficient rooms available on the labour ward and additional beds were created for women who had given birth by placing two women in the same room with only a portable screen separating them."
The report said there was evidence that some senior staff were seen as having an "intimidating style" of management and some midwives were seen as "confrontational" and "abrupt".
But Nigel Ellis, head of investigations at the Healthcare Commission, said they had received "encouraging feedback" since the special measures were introduced.
The North West London NHS Trust said they were "confident" that the situation at the unit had improved but there was still more to do.